Introduction:
The use of vascularised bone grafts such as the free fibula graft has revolutionized the jaw reconstruction surgery procedure, which remains the most challenging procedure in the maxillofacial surgery field. Read the article to know the rationale, implementation, and advantages of free fibula graft in reconstructing the lower jaw or mandible by an oral and maxillofacial surgeon.
What Are the Specifications for Mandibular Reconstruction?
The reconstruction of the mandible or the lower jaw is indeed a complex surgical and challenging procedure for a surgeon. This is because it involves several cosmetic as well as functional challenges that need to be precisely addressed, for instance, the restoration of important functions such as chewing efficiency or mastication and restoring oral competence. Several situations may demand a lower jaw or mandibular reconstruction such as the following:
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Malignant (cancerous) jaw tumors or oral cancers.
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Traumatic injuries.
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Fractures.
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Dentofacial defects.
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Osteoradionecrosis (a medical condition occurring due to the effect of radiation therapy resulting in severe pain and swelling)
The mandible or the lower jaw serves the most important function in the head and neck region with its ability to chew, occlude with the upper jaw, smile with the help of the facial muscles, and with the temporomandibular joint being a hinge joint that protects the facial skeleton.
Though several surgical techniques have been described by dental researchers and clinicians to address these surgical challenges, two main approaches in dental tissue engineering have taken over current oral and maxillofacial surgical procedures in the modern day. For reconstructing the mandible, the oral surgeon uses either the non-vascularized bone grafts (NVBG) or the vascularized bone grafts (VBG). The use of free vascularized fibula graft (a form of VBG), is a popular technique to restore both esthetics and function in dentoalveolar and jaw reconstruction surgeries today.
What Is the Underlying Technique of Free Fibula Graft?
This technique was first introduced by Reverred Hidalgo in 1989 and is touted currently as well by oral and maxillofacial surgeons to be the first option that can be considered for a patient's lower jaw or mandibular reconstruction. The fibula-free flap has undergone several modifications in terms of both requirement and technique ever since its advent in these last three decades.
The advantages of free fibula graft over the other region VBGs are as follows:
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The fibula graft firstly can offer a great length of dense cortical bone, almost nearly up to nine inches in the case of adults. The fibula graft can also offer a long pedicle based on the peroneal artery for reconstructing any specifically long bony defects in the lower jaw region.
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In today's field of oral surgery, with the advent of multiple modifications of the free fibula technique, the surgeon will accordingly customize or design the graft in such a way that can precisely or near approximately fit into a specific individualized defect of the mandible or the lower jaw.
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The prosthodontic reconstruction of the lower jaw or the mandible is one of the surgically complex challenges in modern-day medicine.
One of the minor drawbacks of the use of a free fibula graft is that while the average height of the mandible, including the teeth or the dentition, is generally more than one inch, the average height of the fibula is around half inch. This can pose a reconstructive challenge to the dentist, especially for cases like dental implantation where bone volume needs to be adequate, before dental implant placement. In such cases, the 'double-barreling' of the fibula is a modern-day technique that has been designed that involves osteotomies and the folding over the fibula graft to preserve the blood supply ideally throughout the graft. This can be often combined with the vertical distraction by oral surgeons to expand the neo-mandible almost by up to 0.59 inches to ensure good bone volume. Current success rates for the free fibula graft technique show a whopping 98 % flap survival and good aesthetic results prior to dental implant placement.
Why Is the Free Fibula Graft Considered a Gold Standard Technique When Compared to Others?
The ultimate goal of the oral surgeon whenever there is an impact to the lower jaw either due to trauma, cancers, necrosis, or fractures for instance is to restore at least part of its former efficiency and functionality. The oral surgeon hence may need to evaluate the facial appearance, speech as well as the functions of oral competence, mastication (chewing or grinding), and deglutition (swallowing) prior to the jaw reconstruction surgery pre-operatively. The non-vascularized bone grafts (NVBGs) practiced in the field of oral surgery for a long time may be suitable in specific situations as warranted by the oral surgeon.
This is useful in situations such as in the reconstruction of small traumatic defects of the jaw bone. However, there are several drawbacks or disadvantages to the NVBGs. These can result in a lack of effective blood supply to the region involved which often results in slow and incompetent healing. With the use of only NVBGs, surgeons may often notice post-operative complications such as an increased rate of lower jaw infection, non-union of the graft, or even mandibular or jaw fracture.
Current dental research hence shows that the outcomes from free VBGs, such as the free fibula grafts are known to have a significantly superior impact for long-term success in all jaw reconstruction surgeries. Not only do these technique modifications hold a promising future potential for all surgeons to improve the esthetics and functions of the affected mandible or lower jaw in patients, but also in comparison to the non-vascularized graft options, these are most preferred by today's oral surgeons.
What Is Double Barreling Technique?
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Available options for the VBGs are usually the fibula, radial forearm, scapula, and iliac crest. In comparison to the other regions, the fibula flap remains the popular and gold-standard technique for mandibular reconstruction.
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The specific technique of double barreling of the fibula has been potently demonstrated as an efficient technique that can be utilized according to the individual requirements of the affected individuals undergoing jaw reconstruction surgery.
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These techniques involving the free fibula graft utilize the rationale of osteo-cutaneous flaps that can be harvested for the reconstruction of these complex composite defects of the jaw. 'Double-barreling' of the fibula is done by many oral surgeons commonly in order to restore or rehabilitate the aesthetic and functional demands of the affected individuals. It can be utilized for immediate one-stage dental implants that can be performed by the dental implantologist, prior to osseointegrated dental implantation as well.
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Be it in the field of current-day oral surgery or dental implantology, preoperative virtual surgery planning techniques have been developed over the years to facilitate mandibular construction surgeries effectively. For example, the current concept of "neo-mandible remodeling" is one that is preoperatively performed before the surgeon places the free fibula graft which can ensure the long-term success of the jaw reconstruction surgery.
Conclusion:
The free fibula graft alongside the use of reconstruction plates is a vascularised option for restoring the bony defects whether small or large, in the mandible or the lower jaw. The free fibula bone graft can hence be called the current ‘gold standard’ method implemented by oral and maxillofacial surgeons for mandibular reconstruction. This applies to the restoration of both inner and outer composite defects that occur in the oral cavity.
